Entry Into Prenatal Care --- United States, 1989--1997

Assuring early initiation of prenatal care (PNC) is an important component of
safe motherhood programs, which aim to improve maternal and infant health
outcomes. Women who receive delayed (i.e., entry into PNC after the first 12 weeks of
pregnancy) or no PNC do not receive timely preventive care or education and are at risk for
having undetected complications of pregnancy that can result in severe maternal
morbidity and sometimes death (1,2). Despite overall improvements, the national health
objective for 2000 to increase to at least 90% the proportion of pregnant women who enter
PNC during the first trimester of pregnancy (objective 14.11) was not met
(3). To increase the proportion of mothers receiving early PNC, Congress authorized the
Medicaid expansion program in the mid-1980s, which allowed states to expand
Medicaid eligibility criteria to include formerly ineligible pregnant women
(4). To examine trends in delayed entry into PNC during 1989--1997 and barriers to obtaining early PNC,
CDC analyzed data from two sources. This report summarizes the results of that
analysis, which indicated that although more women are obtaining early PNC,
racial/ethnic disparities still exist and lack of money or health insurance was not the only barrier
to obtaining PNC.

CDC analyzed 1989--1997 birth certificate data for all 50 states and the District
of Columbia to examine the extent to which women in the United States received
delayed PNC or had no PNC. Analysis was restricted to the approximately 4 million live
births to U.S. residents each year and for whom data were available on the month of
their PNC entry.

CDC then used 1997 Pregnancy Risk Assessment Monitoring System
(PRAMS) data for 13 states* to assess reasons for delayed PNC or no PNC among
women. PRAMS is an ongoing, state-based surveillance system that randomly samples
birth certificates and collects information from mothers on pregnancy-related
behaviors and experiences. The 20,345 women in the study represented approximately
842,000 women who gave birth to live-born infants in 1997 in the 13 states for which
response rates exceeded 70%. SUDAAN was used for analysis, and data were weighted
to adjust for survey design, nonresponse, and sampling frame noncoverage.

During 1989--1997, the percentage of women with delayed PNC or no
PNC
decreased from 25% to 18%, with improvement in both delayed PNC (from 22%
to 16%) and in no PNC (from 2% to 1%) (Table 1). The decrease in no PNC during
1989--1997 resulted in an estimated 206,000 additional women entering PNC who may
not have done so had the 1989 rate remained unchanged. Groups more likely to
have delayed or no PNC during 1989--1997 included non-Hispanic blacks, Hispanics,
women aged <20 years, women with <12 years of education, and multiparous
women. However, those same groups generally had larger absolute improvements in
delayed and no PNC during 1989--1997. For example, the prevalence of Hispanic women
with delayed or no PNC decreased from 41% to 26%, and for women aged <20 years,
from 47% to 32%. Improvements in the percentages of women with no PNC occurred for
all racial/ethnic groups during 1989--1995, but then leveled off for non-Hispanic black
and non-Hispanic white women (Figure 1).

Data from 1997 PRAMS indicated that 56% of women with delayed or no
PNC wanted to begin PNC earlier. Reasons for delayed or no PNC varied by
racial/ethnic group, age, or method of payment for PNC (Table 2). The most common reason for not receiving care earlier was "I didn't know that I was pregnant" (non-Hispanic
black [44%], non-Hispanic white [37%], women aged <20 years [47%], and women
whose PNC was paid for by private insurance [44%]). The second most cited barrier to
earlier PNC entry was "I didn't have enough money or insurance to pay for my
visits" (Hispanics [41%], non-Hispanic whites [36%], women aged 20--24 years [36%],
and women whose PNC was paid for by a method other than public or private
insurance [36%]). Among women whose PNC was paid for by public assistance (e.g.,
Medicaid and state programs), 33% cited the latter reason as a barrier to early care. The
third most common reason for not receiving early PNC was inability to get an
appointment (Hispanics [27%] and women aged
>35 years [36%]).

Editorial Note:

During 1989--1997, the prevalence of delayed or no PNC
improved each year among women delivering a live-born infant in the United
States. Improvements in access to early PNC may, in part, be attributed to the
Medicaid expansion program (5). States responded to this change in the Medicaid
regulations by implementing various programs that differed in regards to eligibility criteria
and breadth of assistance (6,7).

Evaluations of Medicaid expansion programs have shown that as more
low-income women become eligible for Medicaid, more of these women accessed early PNC
(8). However, as of 1998, no states had achieved the national health objective for 2000
for early PNC. Although the goals emphasized resolving health disparities, only one
state had reached these goals for black women and no state had achieved them for
Hispanic women (9). In 1997, the percentages of non-Hispanic black women and
Hispanic women with delayed or no PNC remained approximately two times that of
white women, approximately the same as in 1989. Such continuing disparities in
obtaining early PNC mirror the disparities in many reproductive health outcomes among
non-Hispanic black and Hispanic women compared with non-Hispanic white women.

Although Medicaid expansion has contributed substantially to improving access
to early PNC by removing financial barriers for women, a substantial proportion
of pregnant women still did not receive PNC during the first trimester. More than half
of
women with delayed or no PNC would have liked to obtain earlier care, and
these women cited various reasons for delayed entry, with these reasons varying by
group. The most frequent reasons for delay were not knowing that they were pregnant, lack
of money or insurance coverage, and inability to get an appointment earlier.
These reasons suggest a need for improved health education, women's health services,
and coverage of early PNC services.

The findings in this report are subject to at least three limitations. First, the
findings examined only one variable at a time and do not account for overlaps
between demographic and socioeconomic groups of women (e.g., non-Hispanic black
mothers are more likely to be aged <20 years than non-Hispanic white mothers).
Second, although the measure used for initiation of care addresses the timing of PNC
initiation, it does not account for the frequency, quality, or satisfaction with the PNC
received.
Finally, despite being representative of all women delivering a live-born infant in
their states, PRAMS data are only available for a limited number of states and are
not representative of all U.S. births.

Early, high-quality PNC is one of the cornerstones of a safe motherhood
program, which begins before conception, continues with appropriate PNC and protection
from pregnancy complications, and maximizes healthy outcomes for women, infants,
and families. Barriers that keep women from entering PNC must be better understood
to improve maternal health and to eliminate racial/ethnic disparities in the
health outcomes of mothers and infants. Systems such as PRAMS provide the opportunity
to understand the reasons women find it difficult to begin PNC early and to
monitor changes in access to PNC. Only when timely services are available and accessible
to women in their communities can strategies to assure safe motherhood provide
the best start for pregnant women and their infants.

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